Drug-induced hypoglycemia presenting as acute mountain sickness, after mistaking acetohexamide for acetazolamide

Acute mountain sickness (AMS) can present with a wide variety of symptoms in unacclimatized persons who rapidly ascend to altitudes > 2500 m. The clinical manifestations of drug-induced hypoglycemia, including adrenergic and neurologic symptoms, have significant overlap with the AMS symptom complex. These similarities can lead to confusion in the diagnosis of hypoglycemia versus AMS, particularly for diabetics ascending to altitude. A case is described in which the oral hypoglycemic agent acetohexamide, instead of acetazolamide, was mistakenly self-administered for the prophylaxis and treatment of altitude illness. Improper self-medication by travelers in remote areas may be more common than is currently recognized.

A case of acetohexamide-induced hypoglycemia: the influence of hypothyroidism on the metabolism of acetohexamide

Prolonged hypoglycemia induced by acetohexamide (AH) in a patient with noninsulin dependent diabetes mellitus accompanied by primary hypothyroidism was presented. A 74-year-old man who had been treated with AH (500mg, daily) for diabetes mellitus since 1973 was admitted to our hospital in Oct. 1988 because of hypoglycemic coma. On admission, the level of blood glucose was 20mg/dl. Continuous intravenous administration of 10 per cent glucose solution led to improvement in the mental state on the second day. However, the level of blood glucose remained between 30 to 45mg/dl for four days after admission. On the fifth day, a fasting blood glucose level finally reached 75mg/dl. In a thyroid function test, the serum levels of thyroid hormone showed the following decreases: T3 68ng/dl, T4 2.8 micrograms/dl, free T4 0.3ng/dl, while basal TSH levels increased to 50.3 microU/ml. Since anti-thyroid microsomal antibody was positive and thyroid 99mTc-pertechnetate uptake was slightly elevated, the hypothyroidism in this patient was considered to be caused by chronic thyroiditis. Urinalysis was positive for protein. In a renal function test, the blood urea nitrogen was 26.7mg/dl and creatinine 1.7mg/dl, and creatinine clearance decreased to 22ml/min. After thyroid function returned to euthyroid, creatinine clearance improved (41 ml/min). To clarify the relationship between hypothyroidism and the metabolism of AH, the serum levels of AH and its metabolite hydroxyhexamide (HH) following oral administration of AH (500mg) were evaluated before and after thyroxine replacement therapy. The blood glucose level before therapy was lower than that after therapy, and hypoglycemic symptoms were observed early in the second and third morning after AH administration.(ABSTRACT TRUNCATED AT 250 WORDS)

Reversible cholestatic hepatitis caused by acetohexamide

We report a case of cholestatic hepatitis accompanied by peripheral and hepatic eosinophilia in a patient taking acetohexamide for a period of 1.5 yr. Jaundice developed acutely and was accompanied by fever. After discontinuation of the drug, there was no evidence of further damage, with prompt normalization of liver enzymes, bilirubin, and eosinophil count.

Acetohexamide hypoglycemia: treatment by peritoneal dialysis

Acetohexamide hypoglycemia in a patient with renal failure has been successfully treated by peritoneal dialysis. Peritoneal dialysis was done in such a patient, and specimens of serum were collected to measure levels of acetohexamide and its main active metabolite, hydroxyhexamide. During dialysis, hypoglycemia was corrected. After 17 1/2 hours of dialysis, serum acetohexamide level was essentially unchanged. Serum hydroxyhexamide level had decreased at a slower rate than the rate of decrease previously measured in a uremic patient not on dialysis. Although peritoneal dialysis may correct the hypoglycemia, the data suggest that acetohexamide and hydroxyhexamide are not dialyzable. Due to these problems this drug should not be used in patients with chronic renal failure. The drug of choice to control hyperglycemia in patients with renal insufficiency is insulin. If for any reason insulin cannot be used, tolbutamide is the oral hypoglycemic agent of choice.

Inadvertent substitution of acetohexamide for acetozolamide

In three cases acetohexamide (Dymelor), an oral hypoglycemic agent, was mistakenly given to patients instead of acetazolamide (Diamox), which had been prescribed for their glaucoma. A number of similarities, including the fact that both medications are 250-mg white tablets, with similar generic and brand names which are generically repackaged medications juxtaposed on the pharmacist's shelf, predispose to the inadvertent substitution of one medication for the other. In one instance a systemic hypoglycemic reaction resulting in head trauma and confusion ended in an emegency hospital admission following the substitution of acetohexamide for acetazolamide.

Peritoneal dialysis in the treatment of acetohexamide-induced hypoglycemia

Severe hypoglycemia in a 67-year-old black male as a result of the ingestion of acetohexamide is described. Because of both his renal status as well as the severity of the hypoglycemia, the patient received peritoneal dialysis. Sequential specimens of serum, urine and dialysate were collected to measure the levels of acetohexamide and its main active metabolite, hydroxyhexamide. The data indicate that these compounds are not dialyzable. In patients with reduced renal function, peritoneal dialysis may be one way to administer large amounts of glucose with very little administration of fluid in the treatment of acetohexamide-induced hypoglycemia. For those azotemic patients whose hypoglycemia is difficult to manage, intensive dialysis might be a means to correct the abnormality of glucose metabolism imposed by uremia.

Drug-induced hypoglycemia. A review based on 473 cases

Both recognition and prevention of drug-induced hypoglycemia require awareness of the clinical conditions favoring its occurrence and the drugs and drug combinations most likely to cause it. Restricted food intake, age, hepatic disease and renal disease are the main predisposing factors, individually and even more so in combination.

Everyone in general, and insulin-requiring diabetics in particular, should always eat carbohydrate whenever they drink alcohol.

Sulfonylurea hypoglycemia has been reported often in diabetics older than fifty years, with more cases treated with chlorpropamide being reported than cases treated with other sulfonylureas ; it should therefore be used warily in older patients, and only when they are under daily observation by family or friends. In elderly diabetics taking any sulfonylurea agent, warfarin should be used for anticoagulation instead of bishydroxycoumarin, indomethacin for arthritic pain instead of phenylbutazone, and another agent than sulfisoxazole for urinary tract infections. Also in elderly diabetics using sulfonylureas, therapeutic doses of salicylates, monoamine-oxidase inhibitors and probably pro-pranolol should be co-administered with caution, including frequent blood glucose monitoring as long as necessary. Finally, the danger of refractory hypoglycemia in the newborn .proscribes the mother's use of sulfonylureas during the last month of pregnancy.

Drug-induced hypoglycemia is now so relatively common that virtually every unconscious patient should be considered hypoglycemie until immediate estimation of the blood sugar level rules the condition in or out. If it is ruled in, the clinician should promptly start 10 per cent glucose by vein and plan to maintain it uninterruptedly for one or more days, with added hydrocortisone and glucagon if necessary, until persistent hyperglycemia guarantees that all drug effects have worn off.

Neonatal hypoglycaemia in infants of diabetic mothers given sulphonylurea drugs in pregnancy

Three infants whose diabetic mothers were given chlorpropamide and one infant whose diabetic mother was given acetohexamide up to the time of delivery were studied in the neonatal period because each became severely hypoglycaemic. The sulphonylurea drugs given to the mother crossed the placenta, and fetal plasma concentrations were in the therapeutic range for adults with diabetes mellitus. Each baby had severe hyperinsulinaemia resulting in profound hypoglycaemia. These acutely ill infants needed vigorous and prolonged treatment to correct the hypoglycaemia. In two infants exchange transfusion was performed to remove the drug. These sulphonylurea drugs should not be used to control diabetes mellitus in pregnancy.

Prolonged hypoglycemia following acetohexamide administration. Report of two cases with impaired renal function

Prolonged hypoglycemia was precipitated by acetohexamide in two patients with renal failure. In one case the hypoglycemia lasted eight days after withdrawal of the drug, representing the longest recorded such reaction to the sulfonylureas. The cause for the prolonged reactions in these two cases appeared to be the renal retention of acetohexamide metabolites possessing unaltered hypoglycemia potency. A classification of the pathogenesis of prolonged hypoglycemia secondary to sulfonylureas is given and related to the two reported patients.